Critical Care May Not Always Be Right Choice

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Physicians often view the treatment patients receive in intensive
care units (ICUs) as being "futile," a new study finds. What's
more, such care runs up a huge price tag.

More than one in 10 patients received care that a doctor said was
futile during their stay in hospital ICUs, according to the
study, which was conducted by researchers at the University of
California, Los Angeles, and RAND Health in Santa Monica, Calif.

And outcomes were poor: More than two-thirds (68 percent) of the
patients died during their hospitalization, and 20 died within
six months of being discharged from the hospital. Others left the
hospital in "severely compromised health states," the researchers
wrote. Some of these people had severe neurological damage or
were dependent on life-sustaining machines.

In the study, researchers surveyed 36 physicians who cared for
critically ill patients at five ICUs over the course of three
months. In total, the researchers obtained 6,916 assessments of
1,136 patients, who ranged in age from 15 to 99. [ 9
Oddest Medical Cases ]

Eighty percent, or 904 patients, received care that wasn't
considered futile. But 8.6 percent, or 98 patients, received
"probably futile treatment," and 11 percent, or 123 patients,
were perceived to have received futile treatment. One percent, or
11 patients, received futile treatment only on the day they were
transferred to comfort care.

The average cost of one day of futile treatment
in the ICU was $4,004 per patient. The cost of caring for the
123 patients whose treatment was perceived as being futile, both
in and out of the ICU, was $2.6 million, the researchers found.
That accounted for 3.5 percent of the total price tag for the
treatment of patients in the study.

Exactly what doctors perceived to be "futile" treatment varied,
according to the researchers. They found that 58 percent of
physicians perceived treatment to be futile when the burden of
such care vastly outweighed the benefits, while 51 percent deemed
treatment futile if it would never achieve the patient's goals.
Treatment was also thought futile if death was imminent (37
percent), if the patient would never survive outside an ICU
setting (36 percent) or if the patient was permanently
unconscious (30 percent).

Older patients were most likely to receive futile care. For
each decade increase in age, the likelihood of receiving futile
treatment rose by 1.6 percent. Other factors that increased the
likelihood that care would be considered futile included being
sicker, longer hospital stays, being transferred from another
hospital and being cared for in the medical ICU.

"What ICUs are really good at doing is rescuing patients," said
senior study author Dr. Neil S. Wenger, director of the UCLA
Healthcare Ethics Center at the David Geffen School of Medicine.
"A critical-care physician wouldn't want to miss the opportunity
to save someone who could be saved."

"What this study is trying to get at is that physicians are able
to detect when they have done everything," he added. "Even at
that point, they are having difficulty pulling back, largely
because families want to keep pushing forward." Conversations
about end of life care, Wenger said, should happen before a
patient's condition deteriorates.

Critical care in the U.S. accounts for 20 percent of all
health care costs, and 1 percent of the gross national
domestic product, the researchers wrote. Yet 20 percent of deaths
in the U.S. occur during or shortly after a stay in the ICU.

In an accompanying editorial, Dr. Robert D. Truog, of Harvard
Medical School in Boston and Dr. Douglas B. White of the
University of Pittsburgh School of Medicine urged caution in
interpreting and acting upon the study findings.

"Making assessments about potentially inappropriate care is
complex and requires multiple perspectives," they wrote. Many of
the costs of critical care, they added, are "fixed costs that
cannot be eliminated unless critical-care beds are closed."

What's more, many critically ill patients can't speak for
themselves, so they may not be able to make or communicate
decisions about their care, the editorial also noted. While some
clinicians "may believe strongly that it would be wrong to
administer the requested treatments…short of brain death, there
are no criteria or rules to which clinicians can appeal to
justify decisions to refuse life support, at least when those
treatments hold even a small chance of achieving a patient's
goals," the doctors wrote.

The study is published today (Sept. 9) in the journal JAMA
Internal Medicine.